Deck 20: Falls

Question 1

Discharge planning for a patient who lives alone and is at high risk for falling should include telling the patient that he:

A) Cannot go home unless someone is with him all the time.
B) Must go to a long-term care facility.
C) Can wear devices around the neck that can signal for help.
D) Needs to be aware of the dangers of living alone.

Answer 1

Can wear devices around the neck that can signal for help.

Question 2

The older adult patient in a long-term care facility is at risk for injury because of confusion.The patient's gait is stable.To prevent injury to the patient,the best method of restraint if prescribed would be a(n):

A) Geriatric chair
B) Ambularm bracelet
C) Vest restraint
D) Wrist or ankle restraint or both

Answer 2

Ambularm bracelet

Question 3

After a patient has fallen,the most appropriate nursing intervention is to:

A) Apply a vest restraint.
B) Have the patient begin ambulating as soon as possible.
C) Administer haloperidol (Haldol) as prescribed or as needed (PRN).
D) Apply wrist restraints.

Answer 3

Have the patient begin ambulating as soon as possible.

Question 4

The nurse assesses a resident in a long-term care facility with the "Get Up and Go" technique,which involves observing the resident:

A) Walk carefully through a cluttered area without incident.
B) Rise from the bed, and go to the bathroom.
C) Sit and rise from an armless chair.
D) Ambulate in a straight line for 1 foot.

Question 5

The nurse clarifies that the best definition of a fall is a circumstance in which the patient unexpectedly:

A) Falls to the ground, floor, or lower level
B) Loses consciousness, resulting in injury
C) Loses balance, resulting from a lack of equilibrium
D) Injures self, resulting from a side effect of a medication

Question 6

Where should the patient with a visual impairment of the left eye place items that are frequently used to prevent the risk of injury?

A) On the patient's left side
B) In the patient's bathroom
C) In the patient's closet
D) On the patient's right side

Question 7

When caring for a patient who requires wrist restraints,the nurse should remove and release the restraints once every:

A) 8 hours for at least 30 minutes
B) 4 hours for at least 15 minutes
C) 2 hours for at least 10 minutes
D) 1 hour for at least 5 minutes

Question 8

In reviewing a patient's medication administration record,the nurse is aware that some medications are considered to be chemical restraints.Of the following medications,the nurse recognizes the chemical restraint to be:

A) Warfarin (Coumadin)
B) Alprazolam (Xanax)
C) Isosorbide (Isordil)
D) Ibuprofen (Motrin)

Question 9

When the nurse finds that a patient has fallen,the first intervention should be to:

A) Ask the patient to stand up.
B) Document the fall according to agency policy.
C) Remove or correct the cause of the fall.
D) Assess the circumstances of the fall and any injuries sustained.

Question 10

The nurse is talking to the family of a patient who has fallen several times.She knows that her teaching should be aimed toward the most important intervention for falls,which is:

A) Prevention
B) Hospitalization
C) Continuous observation
D) Restraint

Question 11

The older adult patient with osteoporosis is at risk for falls.To maintain safety in the home,the nurse would advise the patient to:

A) Take the rubber mat out of the shower.
B) Install a grab rail in the bath and shower and by the toilet.
C) Avoid rubber-soled shoes.
D) Avoid exercise.

Question 12

The nurse is caring for an older adult patient who has undergone a total hip replacement.To reduce the risk of further injury,the nurse would:

A) Leave all the lights on in the room at night.
B) Leave the side rails down at all times to enable the patient to get to the bathroom quickly.
C) Keep the call bell and other frequently used items in easy reach.
D) Keep the bed in the high position to discourage the patient from getting out of bed without assistance.

Question 13

The nurse is aware that the patient at greatest risk for injury from falls is the:

A) Toddler
B) Teenager
C) Middle-aged adult
D) Older adult

Question 14

The Omnibus Reconciliation Act (OBRA)was enacted to protect patients from unnecessary restraint in long-term care facilities.According to OBRA regulations,one reason to restrain a patient would be if the:

A) Staffing level is inadequate, and nurses are unable to check on the patient at regular intervals.
B) Patient is verbally abusive to the nursing staff.
C) Patient is at an extremely high risk for a fall that is life threatening.
D) Medical procedures cannot be performed because the patient is not being cooperative.

Question 15

The nurse explains that the older adults account for a large percentage of the total deaths resulting from falls.This percentage is:

A) 13%
B) 27%
C) 40%
D) 72%

Question 16

In preparation for discharge home,the nurse caring for a patient with ataxia would recommend that the family:

A) Remove all scatter rugs from the home.
B) Rearrange the bedroom furniture.
C) Arrange for someone to stay with the patient 24 hours a day.
D) Purchase oversized shoes so that they are easy to get on.

Question 17

In assessing the potential risk factors a patient may have for falling,the nurse should keep in mind that the two major factors that cause falls are:

A) Mental and emotional factors
B) Aging and physical factors
C) Genetic and environmental factors
D) Intrinsic and extrinsic factors

Question 18

The nurse in a long-term care facility determines the need to place a vest restraint on a patient.The patient does not want the vest restraint applied.The nurse should:

A) Apply the restraint anyway.
B) Call the physician, and obtain an order for the restraint.
C) Medicate the patient with a sedative, and then apply the restraint.
D) Compromise with the patient and use wrist restraints.

Question 19

The patient has asked the nurse to assist him to ambulate to the bathroom.The nurse is aware that the patient is currently taking an antidepressant medication,so she should:

A) Never leave the patient alone in his room.
B) Ask the patient if he could use the bedside commode instead of going to the bathroom.
C) Make suicidal precautions as part of the care plan.
D) Ask the patient to sit on the side of the bed for a minute or two before standing, and then stand slowly.

Question 20

The nurse is admitting a new patient to the nursing unit.When conducting the admission procedure,assessing the patient's risk for falling is important by asking:

A) "How many times have you fallen before?"
B) "How many hours do you sleep at night?"
C) "What are your eating habits?"
D) "Do you smoke?"

Question 21

The home health nurse recommends to a patient that if a fall occurs at home,the patient should:

A) Assume a crawling position and push up from the floor.
B) Pull self up using sturdy furniture.
C) Roll to a doorway, and pull up using the door knob.
D) Place the right foot flat on floor, and push up on right knee.

Question 22

The nurse points out that people who have a fear of falling may alter their lifestyle to the point that they:

A) Restrict their physical activities.
B) Restrict their social activities.
C) Become more dependent.
D) Have increased need for residency in a long-term care facility.
E) Become depressed.

Question 23

The nurse is aware that many residents in a long-term care facility refuse to wear the hip protector garment and use,as their excuse,that the garment is:

A) Uncomfortable
B) Too expensive
C) Degrading
D) Too easily soiled

Question 24

The nurse is teaching the patient methods for getting up after a fall.The nurse instructs the patient to pull up to a sitting position on the floor,shuffle the buttocks to a nearby piece of furniture,pull up on the knees in front of the furniture,and then:

A) Stand up.
B) Place hands on the floor for leverage.
C) Pivot so that the furniture is behind the body.
D) Sit back down.

Question 25

Family members who brought a patient to the emergency department after she had fallen in her home are expressing their feelings of guilt.The nurse's most therapeutic response to the family would be:

A) "Someone should really be staying with her to prevent her from falling."
B) "Let me see how long it will be before you can see the patient."
C) "Don't worry. You have nothing to feel guilty about."
D) "I can see you are worried."

Question 26

The nurse is discussing the risk of falling with the family of a 75-year-old patient.The family asks,"Why are you so worried about her falling? She falls all the time and doesn't get hurt much." The nurse's response will be related to the fact that:

A) Falls are the most frequent cause of accidental injury and death among older adults.
B) Worrying is probably unnecessary because she hasn't been hurt in the past.
C) Falls usually occur in institutional settings.
D) Falls by older adults are not preventable.

Question 27

A patient with Parkinson disease would be at risk for falling as a result of:

A) Quick movements
B) Unsteady, shuffling gait
C) Hemiparesis
D) Frequent loss of consciousness

Question 28

The nurse suggests that a resident who is at risk for falling come to the ________ ________ class to improve balance.

Question 29

The nurse is aware that of all the reported falls in the United States,only 1% to 5% result in a ____________________.

Question 30

The nurse visiting a patient in the patient's home assesses the environment for extrinsic risk factors for falling.The nurse should have the patient or family correct which one of the following?

A) No door thresholds are present.
B) The kitchen floor is clean, shiny, and slick.
C) Lamps have 60-watt bulbs.
D) The telephone is placed on the bedside table.

Question 31

The nurse helps the physical therapist teach residents in a long-term care facility how to diminish the risk of injury from a fall by teaching them rotation maneuvers to help them avoid falling ____________________.

Question 32

The home health nurse cautions the family of a frail 82-year-old woman about the intrinsic factors that may be a potential cause of injury.These are:

A) Diminished vision
B) Pet cats
C) Cluttered bedroom
D) Wearing loose house slippers
E) Generalized weakness

Question 33

Following the "Rule of Least Restriction," the nurse who is trying to keep a confused resident from removing the feeding tube would replace the wrist restraint with:

A) Mittens
B) Vest restraint
C) Administration of a mild sedative
D) Tightly tucked sheet